Basic Information
| Provider Information | |||||||||
| NPI: | 1588643472 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FEDORWICH | ||||||||
| FirstName: | CHRISTY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 LEWIS RD | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077700025 | ||||||||
| FaxNumber: | 6077293986 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HARRISON ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077636580 | ||||||||
| FaxNumber: | 6077636782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001613 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MP00218800 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 024817 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 001613 | 01 | CT | PHYSICIAN LICENSE | OTHER | 004236007 | 05 | CT | MEDICAID | 1064074 | 01 | CT | NCCPA LICENSE | OTHER | 25MP00218800 | 01 | NJ | STATE | OTHER |